Hi

We have been looking at the case definitions for the clinical events coding (tblCEP). Our UK Register of HIV Seroconverters cohort does not systematically capture such detailed information as listed in the HICDEP case definitions. We ask physicians to report on whether the patient had, for example, 'liver disease' or 'diabetes', leaving it up to the clinician's interpretation, with a space for the clinician to write their own details alongside this in free text (usually quite brief). So, for example, the physician might report diabetes, but we don't know their fasting blood glucose levels unless they happen to have told us, or we have reports of liver diease but we do not necessarily know if it is end-stage liver failure, or the clinician has reported a fracture, but we do not know if they had an xray.

How would you advise we proceed with coding for this table? We would only be able to code and include a tiny small portion of our events data according to these very strict case definitions (when we happen to have that information provided by the clinician). Or would you suggest that we report all clinician identified diabetes, fracture, liver disease, etc for example?

Many thanks

Annabelle